Mumps, mumps vaccination, islet cell antibodies and the first manifestation of diabetes mellitus type I

To connect mumps and diabetes mellitus in children is an old problem in medical literature. The typical occurrence of ICA at the onset of diabetes in children, as well as the incidence of ICA approximately 3 weeks after mumps infection support the hypothesis of a direct relationship between virus infection and diabetes. But the mumps infection alone is not the key factor. Mumps vaccination may not provide protection against diabetes mellitus, it may even provoke it. (Genetic determination, expressed by the HLA-phenotype in all the patients reported, does not allow a differentiation.)

[Hypophosphatemic rickets in premature infants weighing less than 1500 grams on oral and parenteral feeding]

The effect of mode of feeding on the development of rickets in very-low-birth-weight (VLBW) infants in spite of regular vitamin D supplementation was examined. Parenterally fed infants develop rickets more often than orally fed ones in spite of sufficient vitamin D supplementation. On total parenteral feeding hypophosphatemia was observed because phosphate supplementation was significantly lower than on oral feeding or in the intrauterine growing fetus of comparable gestational age. Adequate parenteral phosphate supplementation can prevent rickets.

[Autoimmune phenomena in diabetes mellitus. On the pathogenetic and diagnostic significance]

The detection of islet cell antibodies lead to an increasing interest in autoimmune mechanisms in Typ I diabetes mellitus. Other phenomena such as insulitis in juvenile diabetics and in experimental animals, cellular immune reactions and concomitant antibodies against other endocrine organs, antinuclear antibodies and circulating immune complexes supported these suggestions. HLA-association and viral infections could be predisposing and inducing factors, although there are no clear correlations to any viral infection in a larger number of patients so far. For clinical and therapeutic purposes there are not enough sufficient criteria to demonstrate a pathologic autoimmune process in patients before developing diabetes. Up to now there is no realistic possibility and justification for starting an early immunosuppressive therapy.

[Calcium-phosphate metabolism in pre-term infants]

Physiological and clinical aspects are discussed in this review on calcium-phosphate metabolism in pre-term infants. Calcium accumulation in the bone mass of the foetus is related to the gestational age, and mainly occurs during the last weeks of gestation. Therefore, after birth, hypocalcemia is more frequent in pre-term than term infants. However, clinical symptoms of hypocalcemia, e.g. attacks of apnea, hyperexcitability and hypotonia, are rarely observed. Such symptoms depend upon the serum concentration of ionized calcium and this concentration is influenced by various metabolic factors. During the first two weeks of life phosphate is elevated in comparison to later periods. In spite of sufficient vitamin D supplementation low serum phosphate levels occur due to insufficient supply of phosphate. This correlates with evidence of rickets. An increased alkaline phosphatase activity can be considered an early and sensitive indicator. Pre-term infants develop rickets more frequently than term infants due to calcium-phosphate deficiency. Vitamin D supplementation alone is insufficient and should be combined with phosphate, as had been stated previously.

A new high performance liquid chromatography (HPLC) method for the quantitation of strychnine in urine and tissue extracts

A high performance liquid chromatography (HPLC) method was developed for the quantitation of strychnine in urine of children with nonketotic hyperglycinaemia and other developmental disorders treated with the alkaloid. Mobile and stationary phases were polar, i.e. methanol-water-330 g/kg ammonia (volumes, 85 ml + 14.2 ml + 0.8 ml) and LiChrosorb Si-60, 7 microns. Brucine was the internal standard. Extraction was performed by the Extrelut technique. At strychnine nitrate concentrations in urine of 21, 126, and 70 micrograms/l, recovery was 92.1 +/- 8.7, 98.1 +/- 2.7, and 102.5 +/- 2.7%. A child with nonketotic hyperglycinaemia under continued strychnine treatment excreted 1 to 13.6% of the daily dose unmetabolized in urine. The method was also suitable for the estimation of unreacted strychnine in tissue extracts. The fast disappearance in vitro of strychnine from a guinea pig liver preparation was confirmed.

Wolcott-Rallison syndrome: diabetes mellitus and spondyloepiphyseal dysplasia

In 1972, Wolcott and Rallison described three siblings with a combination of infancy-onset diabetes mellitus and multiple epiphyseal dysplasia. We have observed a brother and sister with the same disorder. The chondro-osseous lesions are those of a spondylo-epiphyseal dysplasia. The diabetes mellitus is relatively mild. Histologic and electron microscopic studies of chondro-osseous tissue show findings similar to those in other epiphyseal and spondylo-epiphyseal dysplasias. In addition, however, atypical collagen-like fibres are found inside and outside chondrocytes. Collagen production seems to be normal in cultured fibroblasts. From the available data it appears that the association of characteristic chondro-osseous and endocrine abnormalities is non-random and that the lesions are independent manifestations of a pleiotropic gene. We propose to call this disorder the Wolcott-Rallison Syndrome.

Excretion of pterins in phenylketonuria and phenylketonuria variants

Total urinary biopterin (B), neopterin (Ne) and monapterin (M) were measured in 25 healthy newborns, children and adults, in 49 patients with phenylketonuria (PKU) assumed to be deficient in phenylalanine-4-hydroxylase (PH), in 7 patients with dihydrobiopterin synthetase (DHBS) deficiency and in 4 patients with dihydropteridine reductase (DHPR) deficiency. Excretion of Ne based on creatinine (Ne/C) was 6.6 times higher in healthy newborns than in adults, suggesting a slow maturation of DHBS activity. Newborns excreted more Ne than B and adults more B than Ne (32 and 72% B of the sum of B + Ne, respectively). In all cases, excretion of M was 4-15% of that of Ne. PH deficient patients excreted more B and Ne than healthy controls and again, newborns more than older children. In individual patients, excretion of pterins correlated with phenylalanine (Phe) concentration in plasma; plasma Phe of different patients did not correlate well with excretion of pterins. In PKU variants with deficiency of tetrahydrobiopterin (BH4), extreme pterin patterns were observed: in DHBS- and DHPR-deficient patients, less than 3.5 and more than 81% B were found, respectively. All 30 samples from these patients investigated could be distinguished from those of PH-deficient patients and controls by a two-dimensional plot of % B versus B/C. Thus it seems likely that PKU variants due to BH4 deficiency could be detected early and differentiated by measurement of urinary B, Ne and C. This was exemplified already in one case. - In urine of patients with DHBS deficiency, high concentrations of 3'-hydroxysepiapterin were found in addition to Ne.

[Sudden death caused by massive air embolism during respirator therapy in the newborn]

A premature male infant with hyaline membrane disease succumbed suddenly during continuous positive pressure respirator therapy. Autopsy revealed a very rare complication to be the cause of sudden death: air embolization to pulmonary veins, right ventricle and superior and inferior venae cavae as well as interstitial and subpleural emphysema, pneumothorax, pneumomediastinum and pneumopericardium. The important role of lymphatic vessels as a port of entry for air is stressed.

Nonketotic hyperglycinemia treated with strychnine, a glycine receptor antagonist

A 6 1/2-month-old boy suffering from nonketotic hyperglycinemia has been treated for at least 12 months with oral strychnine. The drug caused improvement of muscle tone, motoricity, vigilance and social behavior. Glycine is one of the putative neurotransmitters of postsynaptic inhibition, particularly at the spinal and reticular levels, strychnine its antagonist at the postsynaptic membrane. Strychnine improved the patient's motoricity presumably by blocking the excessive glycine-mediated inhibition of motoneurons. The beneficial effect of strychnine on vigilance and social behavior is more difficult to explain but may have been related to its antagonism of glycine inhibition of brainstem reticular neurons.

The use of a crystalline amino acid mixture for parenteral nutrition in low-birth-weight infants

Thirty-six preterm, sick, low-birth-weight neonates were given either total or partial parenteral nutrition. The patients were divided into three groups according to their birth weights: group A -less than 1,000 gm, 12 patients: group B--between 1,000 and 1,500 gm, 15 patients: group C--more than 1,500 gm, 9 patients. The solution for total parenteral nutrition contained 20% glucose and 2.6% crystalline amino acids plus appropriate amounts of vitamins and minerals. The volume of infusate given was usually 125 ml/kg/day, but varied depending on the clinical condition of the patient; occasionally it was as high as 150 to 175 ml/kg/day. Infusate of one-half strength was administered initially; its concentrations of glucose and amino acids were increased to three quarters and full strength gradually, if tolerated. The solution for total parenteral nutrition was infused into the superior vena cava via a central venous catheter; that for partial parenteral nutrition was given into a peripheral vein to supplement inadequate oral feedings. The period of parenteral nutrition lasted from 5 to 49 days, with an average of 13.2 days. The intake of 500 mg of nitrogen as crystalline amino acids and 100 kcal as glucose was capable of achieving body weight gain. Positive nitrogen balance of various degrees was also observed. Hyperglycemia of a slight to moderate degree was observed in nine patients; only three required insulin therapy. Two patients had thrombotic occlusion of the central venous catheter. The conclusion was reached that total parenteral nutrition or partial parenteral nutrition, when properly managed, is a safe procedure in small, premature infants. The amino acid solution given as a nitrogen source along with adequate calories was effective in promoting weight gain and nitrogen balance; it was apparently well tolerated by low-birth-weight neonates.